The Oaks at Belmont: Untreated Pressure Wounds - MI
Federal inspectors documented the discovery during an unannounced visit to The Oaks at Belmont in August. Two registered nurses had entered the resident's room and immediately noticed her bedding and shirt were soaked with brown-discolored fluid.
Neither nurse wore the required protective gowns for direct contact with the resident, who was on enhanced barrier precautions.
When staff helped turn Resident 104 onto her left side, they found extensive damage. Her buttocks were red and macerated with deep creases from the bedding. Multiple pinpoint areas showed bright red bleeding. The nickel-sized wound on her left buttock was covered in slough, the stringy dead tissue that prevents healing.
No topical cream was visible on the resident's skin.
RN F told inspectors that certified nursing assistants were responsible for applying topical medications, including the prescription Triad cream ordered twice daily for this resident. The thick cream would still be visible if applied that day, the nurse explained.
Staff searched the room for Triad cream but couldn't locate it. Instead, they applied petroleum barrier cream over the resident's entire buttocks area.
The nurses didn't clean the resident's front side or provide catheter care. RN F explained that the fluid soaking the bed wasn't urine but drainage from the resident's legs, and morning incontinence care should have already been completed by a nursing assistant.
The resident's protective boot for her right foot was missing, reportedly sent to laundry.
Facility records revealed no current documentation of wounds on Resident 104's buttocks or feet in the wound management reports. The omission was significant given what inspectors observed.
Medical records showed a history of serious pressure ulcers. A previous pressure ulcer on the left buttock had extended slightly into the right buttock. A stage 3 pressure ulcer on the left lower buttocks had also been documented. Both wounds were marked as resolved on May 7, 2025.
Records also showed history of an unstageable pressure wound on the left heel.
Assistant Director of Nursing C confirmed to inspectors that staff must wear gloves and gowns when providing direct care and changing linens for Resident 104. The Triad cream, she explained, should be applied twice daily by nursing staff and kept in the medication cart.
At the time of the inspection, ADON C reported that Resident 104's Triad cream was not found in her room or the medication cart.
The facility had recently implemented new procedures after discovering pressure ulcer problems with another resident. Under the new process, nursing assistants were required to document any skin concerns on observation forms and submit them to nurses and the director of nursing.
No skin observation forms existed for Resident 104.
The inspection report included detailed medical guidance about wound assessment that staff had failed to follow. When wounds are identified, closer assessment is required to plan appropriate care. The assessment should include the amount and appearance of viable and nonviable tissue.
Slough, the soft yellow or white stringy substance found in Resident 104's wound, must be removed by qualified clinicians or appropriate wound dressings before healing can occur. Black, brown, or tan necrotic tissue also requires removal before healing begins.
Excessive wound drainage indicates possible infection. The skin around wounds should be examined for redness, warmth, and signs of maceration. Staff should check for pain or hardening of tissue.
Any of these factors indicate wound deterioration.
The citation carried a designation of "actual harm" affecting few residents. The violation involved the facility's failure to provide necessary care and services to prevent new pressure ulcers and heal existing wounds.
Federal regulations require nursing homes to ensure residents receive treatment and care in accordance with professional standards of practice. The facility must also maintain accurate, complete, and easily accessible clinical records for each resident.
Resident 104's case revealed multiple system failures: missing prescribed medication, inadequate wound documentation, staff not following infection control protocols, and failure to identify and report deteriorating skin conditions through the facility's own new reporting system.
The resident remained at the facility with wounds that medical literature indicates would continue deteriorating without proper assessment and treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Oaks At Belmont from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
The Oaks at Belmont in Belmont, MI was cited for violations during a health inspection on August 11, 2025.
Federal inspectors documented the discovery during an unannounced visit to The Oaks at Belmont in August.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.